Henry Frazier left a Rocky Ford nursing home with a fist-size necrotic abscess from a bedsore — and died in hospice.

A jury awarded the family $3.2 million for negligence by Pioneer Healthcare, a nursing home in a building where Frazier had once worked as a janitor.

An expert found Frazier had suffered 16 facility-acquired infections in his time at Pioneer and an “appalling” 34 injuries.

National safety panels consider Stage 4 bedsores such as Frazier’s to be “never events,” so unthinkable in a health facility that they include electrocuting a patient or amputating the wrong limb.

And yet the state’s review of the case produced no citation, no penalty and no consequence for Frazier’s wound or death.

“The allegation of the facility failing to properly assess or treat a resident who was at risk for pressure sores was substantiated,” according to a complaint investigation summary filed by the state. Still, state nursing home investigators concluded, “the facility was not cited with deficient practice because the investigation did not substantiate current deficient practice.”

That kind of bureaucratic doublespeak angers patient advocates and nursing home watchdogs, who say state health departments too often go easy on corporate owners in even the most egregious cases.

“State survey agencies frequently fail to cite facilities for harming residents, even when they find serious injuries,” said a report by the National Citizens’ Coalition for Nursing Home Reform, now called Consumer Voice.

The Colorado Department of Public Health and Environment said, in written responses to questions, “There was a lack of information from record review and interviews that showed the facility failed to act appropriately in response to the wound.”

In defending against the Frazier family’s negligence lawsuit in Otero County District Court, Pioneer said Frazier died of complications from his longtime Parkinson’s disease. Frazier was recovering from the pressure sore when he died, attorneys told the jury.

The Frazier family remains incensed that no one at the state found fault with his care.

“Bedsores are not unavoidable,” said daughter Wanda Frazier, who lives in Littleton. “They didn’t even tell any of us how sick my dad was, how bad the sore was. It’s pretty horrific.”

Wanda Frazier said the family reported their father’s gaping wound to police and state Adult Protective Services as well as to the state health department. The family said none took any action.

Henry Frazier’s family first checked him into Pioneer, owned by a Tennessee-based group of nursing homes called Grace Healthcare, in May 2009. Nutrition deficits and other challenges from Parkinson’s put Frazier at risk for bedsores and other nursing complications, and the home was required to have a care plan in place.

Wanda Frazier said that in late August or early September of 2010, a nursing aide mentioned to her mother, Marietta, that Henry had a small sore and they were watching it.

By late September, an aide was telling the family the wound was bigger and beginning to smell of rot; son Mark Frazier, with a power of attorney, finally saw the severity of the wound and demanded the nursing home send Henry to a hospital. Pictures show a gaping hole in Frazier’s buttocks, spreading to his scrotum and other areas.

Pioneer’s trial attorney, Thomas Quinn, said staff had properly cared for Frazier before and after the wound, and doctors ordered treatment.

“There was no dispute that those care orders were followed,” Quinn said.

Frazier’s death certificate listed the primary cause of death as MRSA, a notoriously hard-to-treat infection. Quinn said supplemental details on the certificate also listed Parkinson’s and resulting malnutrition as underlying causes.

Pioneer maintains Frazier was recovering from the wound when food aspiration and weakness from Parkinson’s killed him Dec. 3, 2010.

Jeannie Seeley, a nursing expert hired by the family’s lawyer, reviewed the nursing home and hospital charts and wrote that in several areas, “the care provided to Mr. Frazier fell far below the standard of nursing care and wound care.” She said the home used outdated wound treatments, failed to shift his weight to avoid sores, failed in charting his care and didn’t raise questions about his “appalling wound” until Mark Frazier insisted.

The state took the family complaint in October 2010 and investigated. Colorado, following federal and state rules, has the power to write up deficiencies, demand corrections and impose penalties up to revoking the facility’s license to operate.

The pressure sore did develop in the nursing home, the state found, but it was not clear from the files and interviews that the home neglected Frazier’s care, officials said.

Asked whether the investigation revealed the same long list of infections and injuries cited by the expert witness, McCants said: “We reviewed approximately one year of information, and were aware of the issues.”

But because “no deficient practice was found,” according to official definitions, the probe resulted in no consequence for Pioneer.

The Rocky Ford home did get hit in a regular state “survey” weeks later, in January 2011. The state found 27 deficiencies, including infection control, avoidance of patient hazards and incomplete care plans.

The state says the January survey was unrelated to the Frazier case. A revisit in March 2011 found five deficiencies were not corrected, and Medicare and Medicaid payments for new Pioneer patients were suspended. A second revisit in May 2011 found all the problems corrected.

Daughter-in-law Barbara Frazier said she finds it ridiculous the state reviewed so many files in late 2010 for Henry’s case and found nothing, then cited 27 “deficiencies” in January 2011.

“This just should not happen in a nursing home,” Barbara Frazier said. “I don’t buy for a minute that Parkinson’s killed him.”

Asked about the difference between the jury’s reaction and the state’s conclusions, attorney Quinn said, “The jury had an emotional response to an emotional case. What the state sees is something different than what they jury might see in a case like this.”

Patient advocates say the U.S. Government Accountability Office has cited similar cases from state after state, where apparently egregious nursing home treatment is ignored or dismissed by “timid” oversight.

The states focus on facility paperwork and federal regulations, leaving patients’ families out of the equation, said Toby Edelman, senior policy attorney for the Center for Medicare Advocacy.

“They’re not getting any satisfaction (out of regulators),” Edelman said. “The residents and families are incidental to the system.”

Private lawsuits are one way for families to fight back, advocates note.

The Fraziers are not yet guaranteed the $3.2 million judgment — Colorado law caps many wrongful-death cases at $300,000 in damages. Attorney Jerome Reinan hopes to raise that cap by arguing the award was for care that went beyond the negligent and into the “reckless.”

Meantime, the family has another bureaucratic contradiction to fight. Medicare and its designated state investigators found no cause to pursue the nursing home in the Frazier case.

Yet now that the Fraziers have won a judgment, Medicare put a lien on the award for thousands of dollars — the money it paid out for Henry Frazier’s wound care.

Michael Booth was a health care & health policy writer at The Denver Post before departing in 2013. He started his journalism career as an assistant foreign editor at The Washington Post before moving with family to Denver and taking a brief stint with the Denver Business Journal. During a 25-year career at The Post, he covered city and state politics, droughts, entertainment and wrote Sunday takeouts, and was part of two Pulitzer Prize-winning teams for breaking news coverage.

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